Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal

Case Presentation

An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2 days’ duration. She had been hospitalized for pneumonia one week earlier. Her vitals on arrival were: Blood Pressure: 138/84 mmHg, Pulse Rate: 65 beats per minute, Respiratory Rate: 14 breaths per minute, Body Temperature: 37°C (98.6°F), Oxygen Saturation: 96%. On examination, her right calf was reddish, tender, edematous and 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Her Wells’ Score for deep vein thrombosis (DVT) was 4 and suggested high-risk for DVT. Compression ultrasonography showed a thrombus in the popliteal vein. Enoxaparin (1 mg/kg, twice a day, SC) was started. No signs and symptoms of pulmonary embolism were observed. The patient was referred to a cardiovascular surgeon as an outpatient after discussion and confirmed understanding of discharge instructions.

Introduction

The annual incidence of DVT is 92 cases per 100000 persons. The rate steadily advances with increased age (32/100000 if age < 55 years, 282/100000 if age 65-74 years, 555/100000 if age >74). While 90% of DVT occurs in lower extremities, 10% of DVT occurs in upper extremities. Up to more than 40% of patients with lower extremity DVT have concomitant pulmonary embolism (PE), whether they may have related complaints or not.

Critical Bedside Actions and General Approach

DVT is mostly a relatively benign disease; nevertheless, it may cause severe symptoms and limb- or life-threatening presentations. Emergency physician (EP) must check for signs of adverse outcome. Therefore patients should be evaluated for airway, breathing, circulation sequence and EPs try to understand possible immediate life-threatening problems. Concentrating on the patient focal complaint should be followed after the initial evaluation. Check vitals for instability and fever. Check for arterial pulses and signs of acute arterial thrombosis immediately in the case of every limp pain. Also, an extremely or entirely swollen limb indicates total or near total obstruction at a more proximal level. Increased compartment pressure may potentially disrupt the arterial flow. Diagnosing DVT in the emergency department (ED) is crucial. A timely started treatment may prevent the subsequent pulmonary embolism (PE) and chronic morbidities like chronic venous stasis and recurrent clots.

Some patients may ignore PE-related mild symptoms, or they may give priority to DVT-related ones. EP must concentrate on subtle PE-related sign and symptoms. In the spectrum of DVT, phlegmasia alba dolens, phlegmasia cerulea dolens and venous gangrene are vascular emergencies. They should be managed surgically, by endovascular interventions or thrombolytic treatment, in a time-sensitive manner. Upper extremity DVT has its own risk factors and consequences. It should be managed in its own context.

Differential Diagnosis

Table 1 summarizes differential diagnoses of DVT. Unilateral and bilateral leg swelling and pain are two categories in order to differentiate the various causes. Bilateral leg swelling is more likely a clue for congestive heart failure, liver or renal failure, inferior vena cava compression than the bilateral DVT. However, patients symptoms and findings should be considered for ruling out these causes.

History and Physical Examination Hints

Neither medical history nor physical examination is specific to DVT. Clinical presentation may range from nearly asymptomatic to severely symptomatic or limb- or life-threatening.

As a general rule, unilateral limb pain and swelling imply DVT.

Lower extremity DVT

Unilateral leg pain and swelling are indicators of lower extremity DVT. Some patients may define fullness or cramping in the posterior aspect of the lower extremity. Bilateral symptoms are more likely in the course of other diseases. However, simultaneous bilateral DVT or obstruction of the inferior vena cava may cause bilateral symptoms.

Edema, redness, and tenderness are possible signs. None is specific. Homans sign refers to calf pain elicited by passive dorsiflexion of the ankle. It is insensitive and nonspecific, therefore, useless.

Because only history and examination are indeterminate, risk factors for DVT are essential to predict clinical probability. Known risk factors for DVT are as follows:

Previous history of PE or DVT

Recent Trauma or surgery

Cancer

Central or long-term vascular catheter

Age

Oral contraceptives

Hormone replacement therapy

Pregnancy

Immobility

Factor V Leiden mutation

Antiphospholipid antibody syndrome

Prothrombin mutation

Hyperhomocysteinemia

Deficient levels of clotting factors

Congestive heart failure

Chronic obstructive pulmonary disease

Air travel

Obesity

Phlegmasia alba dolens and phlegmasia cerulea dolens are vascular surgical emergencies. The features of these conditions are summarized in Table 2.

Surgical Emergencies Secondary To DVT

Phlegmasia alba dolens

Phlegmasia cerulea dolens

Appearance

Pale, cool, edematous
(An example is available at https://www.thrombosisadviser.com/html/images/library/vte/deep-vein-thrombosis-right-leg-HR.jpg)

Cyanosed, edematous, purple ecchymosis
(An example is available at http://circ.ahajournals.org/content/125/8/1056/F1.expansion.html)

Please read http://emedicine.medscape.com (accessed at 10.05.2016) for more information.

The indications for more advanced therapies like catheter-directed thrombolysis, percutaneous mechanical thrombectomy, conventional surgery or systemic thrombolysis are as follows:

Phlegmasia cerulea dolens

Inferior vena cava thrombosis

Subacute and chronic iliofemoral DVT

Acute iliofemoral or femoropopliteal DVT

Though all are useful, endovascular interventions are preferred over more invasive interventions in capable centers so as to minimize the consequent risks. (Bleeding or perioperative complications, etc.)

The pain medication is advised for patients who are suffering from severe pain.

Pediatric, Geriatric, Pregnant Patient and Other Considerations

Pediatric Considerations

DVT is infrequent in children and almost always associated with risk factors. Central venous catheter-associated upper extremity DVT is relatively common in children. LMWH is the mainstay of the therapy.

Enoxaparin:

<2 months: 1.5 mg/kg/dose SC, twice a day

>2 months: 1.0 mg/kg/dose SC, twice a day

Geriatric Considerations

DVT management does not alter in the elderly. Frequency and severity of DVT increase. Anticoagulation complications are more frequent than younger counterparts. Concomitant diseases and possible drug interactions complicate the management.

Pregnant Patients

DVT management does not alter in pregnant. Pregnant women are susceptible to DVT. LMWHs are the drug of choice during pregnancy. All pregnant patients with DVT should be admitted to hospital.

Patients With Isolated Calf Vein Thrombosis

The need for treatment is controversial.

Disposition Decisions

Admission Criteria

Most patients with DVT can be treated as outpatients. EP can decide the patients that need admission based on four questions (link).

Does the patient have massive DVT?

Does the patient have symptomatic pulmonary embolism?

Is the patient at high risk for anticoagulant-related bleeding?

Does the patient have major comorbidity or other factors that warrant in-hospital care

One or more positive answers should lead EP to admission.

Consider admission if any is present:

Suspected or proven concomitant PE

Significant cardiovascular or pulmonary comorbidity

Iliofemoral DVT

Contraindications to anticoagulation

Familial or inherited disorder of coagulation

Familial bleeding disorder

Pregnancy

Morbid obesity (>150 kg)

Renal failure (creatinine >2 mg/dL)

Unavailable or unable to arrange close follow-up care

Unable to follow instructions

Homeless patient

No contact telephone

Geographic location (too far from the hospital)

Patient/family resistant to outpatient therapy

Discharge Criteria

All patients lacking admission criteria may be treated as outpatients after a confirmed understanding of discharge instructions. Several discharge instructions are available online.

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